Page 39

Effective Date: April 1, 2009

Approval Date: ____________ 36

This Page Relates to Plan "D" Only

6.2.A.10.

Inpatient mental health services, other than services described in 6.2.A.18, but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.A.11.

Outpatient mental health services, other than services described in 6.2.A.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.A.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.A.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.A.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.A.15.

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.A.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.A.17.

Dental services (Section 2110(a)(17)) 6.2.A.18. Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.A.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.A.20.

Case management services (Section 2110(a)(20)) (chronically ill) 6.2.A.21.

Care coordination services (Section 2110(a)(21)) 6.2.A.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.A.23.

Hospice care (Section 2110(a)(23)) 6.2.A.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.A.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) (Plan D) 6.2.A.26.

Medical transportation (Section 2110(a)(26)) 6.2.A.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.A.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

See NJ FamilyCare Plan D chart, Attachment 6, for detailed description of coverage, amount, duration and scope, as well as any exclusions or limitations.